有再表再里。或再表里分传者。医家不解。反责病患不善调养。以致反复。病家不
解。反咎医师疏于救治。彼此归怨。胥失之矣。不知病势之当然。其气性如此。
邵评∶疫症是秽浊之邪。不正之气。伏膜原而布三焦。其邪之或结或开。或表或里。本无一定。故多
表而再表。里而再里。表里分传再见之症。此病情之传变不常。邪气之聚散无定。乃病势之当然。非关调治
之失宜。然必病者元气不虚。方可随症施治。若虚弱之体。恐未能当此缠扰耳。疫症之外。若风寒温暑湿热诸
病。则鲜如此见症也。
先表后里者。始则但有表证。而无里症。宜达原饮。有三阳经症者。加三阳经药。继而脉大而数。
自汗而渴。邪离膜原。未能出表。宜白虎汤辛凉解散。邪从汗解。脉静身凉而愈。二三日后。或四五
日后。依然发热尚宜达原饮。至后反加胸满腹胀、不思谷食、烦渴等证。加大黄下之。
邵评∶邪从口鼻吸受。先由肺入。肺主皮毛。则先见表症。有头疼身痛发热凛寒
之象。用达原饮以宣其邪。三阳者。太阳阳明少阳也。故太阳加羌活。阳明加葛根。少阳加柴胡也。
先里后表者。始则发热。渐盖理证。下之便愈。后复发热。反加烦疼。身重脉浮者。宜
白虎汤主之。不得汗者。津液枯竭也。加人参。覆杯即愈。
邵评∶瘟疫自口鼻而入。直行中道。伏于膜原。膜原为半表半里。其邪自内出外。故有先见里症。可
先下之。下后里通。邪渐出外。在阳明之经。故见烦热脉浮身疼重之症。再用白虎汤以清之。不得汗者。正
虚液竭。白虎加人参。以扶正达邪。若大汗大下后。表里之证悉去。继而一身尽痛。身如被杖。脉沉
细者。此汗出太过。
阳气不周。骨寒而痛。非表证也。此不必治。二三日后阳回自愈。
邵评∶汗下之后。表里之症虽去。而津亏气弱。不能营养筋骨脉络。故痛如被杖。用药宜养营和阳之剂。
又评∶瘟疫与伤寒大异。伤寒不可早下。瘟疫有先里后表之症。故可先下。下之
里通而表达。盖瘟疫之邪自内达外。与伤寒先表后里之治不同法。此瘟疫伤寒分泾渭处也。
有病情反复经过两次解表、两次攻里的情况。或者病邪在表里之间分途传变的。医生不理解，反而责怪病人不善于调养，导致病情反复。病人不理解，反而怪罪医生救治疏忽，彼此互相埋怨，都错了。不知道这是病势发展的必然规律，病邪的气性就是如此。
邵评：瘟疫是秽浊的邪气，不正之气，潜伏在膜原而散布于三焦。它的邪气或结聚或开散，或在表或在里，本来没有定规。所以多见先解表再解表，先攻里再攻里，表里分传的症状再次出现的情况。这是病情传变的不寻常，邪气聚散无定，乃是病势的必然，与调治是否适宜无关。但是必须病人元气不虚，才可以随症施治。如果是虚弱体质，恐怕不能承受这种纠缠困扰罢了。除了瘟疫之外，像风寒温暑湿热等病，很少见到这样的症状。
先解表后攻里的情况。开始只有表证，而没有里证，宜用达原饮（Da Yuan Yin, Origin-Reaching Powder）。如果有三阳经症状的，加入三阳经的药物。继而脉象大而数，自汗且口渴，邪气离开膜原，但未能透出体表，宜用白虎汤（Bai Hu Tang, White Tiger Decoction）进行辛凉解散。邪气通过汗液排出而痊愈。两三天后，或者四五天之后，依然发热，仍宜用达原饮。到了后来反而出现胸满腹胀、不想进食、烦躁口渴等症状，加大黄（Rhei Radix et Rhizoma, 大黄）来攻下。
邵评：邪气从口鼻吸入，先从肺进入。肺主皮毛，所以先出现表证，有头痛身痛、发热恶寒的现象。用达原饮宣散邪气。三阳经，指太阳、阳明、少阳。所以太阳经加羌活（Notopterygii Radix, 羌活），阳明经加葛根（Puerariae Radix, 葛根），少阳经加柴胡（Bupleuri Radix, 柴胡）。
先攻里后解表的情况。开始发热，逐渐转为里实证，攻下即可痊愈。后来再次发热，反而增加烦躁疼痛、身体沉重、脉浮的症状，宜用白虎汤主治。如果不得汗出，是津液枯竭的表现，加入人参（Ginseng Radix, 人参），喝完药杯即愈。
邵评：瘟疫从口鼻进入，直行中道，潜伏在膜原。膜原是半表半里之地，邪气从内向外透发，所以先见到里证，可以先用攻下法。攻下后里气通畅，邪气逐渐向外透发，在阳明经，所以出现烦躁发热、脉浮、身体疼痛沉重的症状。再用白虎汤来清解。如果不得汗出，是正气虚弱、津液枯竭，用白虎加人参汤以扶助正气、驱除邪气。如果在大汗大下之后，表里之证全部去除，继而全身尽痛，身体像被棍棒打过一样，脉象沉细的，这是出汗太过，阳气不能周流全身，骨骼寒冷而疼痛，不是表证。这种情况不必治疗，两三天后阳气回复自然痊愈。
邵评：汗法和下法之后，表里之症虽然去除，但津亏气弱，不能营养筋骨脉络，所以疼痛如被杖打。用药宜用养营和阳的方剂。
又评：瘟疫与伤寒大不相同。伤寒不可以过早攻下，瘟疫有先里后表的病症，所以可以先攻下。攻下后里气通畅而表邪外达。这是因为瘟疫的邪气从内达外，与伤寒先表后里的治疗方法不同。这是区分瘟疫和伤寒的关键所在。
There are cases of repeated exterior resolution and repeated interior purgation. Or cases where the pathogen transmits separately between the exterior and interior. Physicians who do not understand this may blame the patient for poor self-care, leading to recurrence. Patients who do not understand may blame the physician for negligent treatment, resulting in mutual resentment; both parties are mistaken. They fail to realize that this is the natural progression of the disease pattern; the nature of the pathogenic factor is such.
Shao's Commentary: Epidemic febrile diseases (Yi Zheng) are caused by turbid pathogens and aberrant qi, which lodge in the Mo Yuan (Membrane Source) and spread throughout the San Jiao (Triple Burner). The pathogen may aggregate or disperse, remain in the exterior or penetrate to the interior, without a fixed rule. Therefore, it is common to see repeated exterior resolutions, repeated interior purgations, and the reappearance of symptoms involving separate transmission between the exterior and interior. This reflects the irregularity of disease transmission and the unpredictable aggregation and dispersion of pathogens, which is the natural course of the disease, unrelated to improper treatment. However, this approach is only feasible if the patient's Yuan Qi (Primary Qi) is not deficient. For patients with a weak constitution, they may not withstand such prolonged and complicated conditions. Aside from epidemic febrile diseases, patterns such as Wind-Cold, Warmth, Summer-Heat, and Damp-Heat rarely present with such symptoms.
Exterior Resolution Followed by Interior Purgation: Initially, there are only Exterior Syndrome (Biao Zheng) manifestations without Interior Syndrome (Li Zheng) manifestations. Da Yuan Yin (Origin-Reaching Powder) is indicated. If symptoms of the Three Yang Meridians (Taiyang, Yangming, Shaoyang) are present, herbs corresponding to these meridians should be added. Subsequently, if the pulse becomes large and rapid, accompanied by spontaneous sweating and thirst, indicating that the pathogen has left the Mo Yuan but failed to exit via the exterior, Bai Hu Tang (White Tiger Decoction) should be used for acrid-cool dispersal. The pathogen resolves through sweating, and the pulse becomes calm while body temperature normalizes, leading to recovery. After two or three days, or four or five days, if fever persists, Da Yuan Yin may still be appropriate. Later, if chest fullness, abdominal distension, anorexia, irritability, and excessive thirst appear, Rhubarb (Rhei Radix et Rhizoma) should be added to purge the interior.
Shao's Commentary: Pathogens enter via the mouth and nose, first entering the Lung. Since the Lung governs the skin and hair, Exterior Syndromes appear first, manifesting as headache, body pain, fever, and aversion to cold. Da Yuan Yin is used to diffuse the pathogen. "Three Yang" refers to Taiyang, Yangming, and Shaoyang. Therefore, Notopterygium (Notopterygii Radix) is added for Taiyang, Kudzu Root (Puerariae Radix) for Yangming, and Bupleurum (Bupleuri Radix) for Shaoyang.
Interior Purgation Followed by Exterior Resolution: Initially, there is fever, which gradually progresses to a Replete Interior Syndrome (Li Zheng), resolvable by purgation. Later, fever recurs, accompanied by increased irritability, pain, heaviness of the body, and a floating pulse. Bai Hu Tang is the primary formula. If sweating does not occur, it indicates exhaustion of Body Fluids (Jin Ye); Ginseng (Ginseng Radix) should be added, and recovery follows quickly after ingestion.
Shao's Commentary: Plague pathogens enter via the mouth and nose, traveling directly along the central pathway and lodging in the Mo Yuan. The Mo Yuan is located at the half-exterior, half-interior level. As the pathogen moves from the interior to the exterior, Interior Syndromes appear first, allowing for initial purgation. After purgation, the interior becomes unobstructed, and the pathogen gradually emerges outward, affecting the Yangming Meridian. This manifests as irritability, heat, floating pulse, body pain, and heaviness. Bai Hu Tang is then used to clear the heat. Lack of sweating indicates deficiency of Righteous Qi (Zheng Qi) and depletion of fluids; Bai Hu Tang plus Ginseng is used to support the righteous Qi and expel the pathogen. If, after severe sweating and purgation, all exterior and interior syndromes resolve, followed by generalized body pain resembling being beaten with a club, and a deep, fine pulse, this is due to excessive sweating causing Yang Qi to fail to circulate uniformly, resulting in cold bones and pain. This is not an Exterior Syndrome. It requires no specific treatment; after two or three days, when Yang Qi returns, it will heal spontaneously.
Shao's Commentary: After sweating and purgation, although exterior and interior symptoms have resolved, the deficiency of fluids and weakness of Qi fails to nourish the sinews, bones, and collaterals, causing pain as if beaten. Medication should focus on nourishing Ying (Nutritive) Qi and harmonizing Yang.
Additional Commentary: Epidemic febrile diseases differ significantly from Cold Damage (Shang Han). In Cold Damage, purgation should not be performed prematurely. However, epidemic febrile diseases may present with Interior Syndromes preceding Exterior Syndromes, allowing for early purgation. Purging clears the interior and facilitates the release of the exterior. This is because epidemic pathogens move from the interior to the exterior, differing from the treatment principle of Cold Damage, which addresses the exterior before the interior. This distinction marks the clear separation between epidemic febrile diseases and Cold Damage.